A middle-aged blue-collar employee complains of frequent headaches and jaw soreness. They also report teeth clenching, stress, and poor sleep. Upon examination, a dentist notes signs of tooth wear and masseter muscle hypertrophy. This is a case of behavioral sleep bruxism. 

In contrast, there is a senior patient who suffered a mild stroke six months ago. Jaw discomfort and frequent biting of the inside of the cheek are the two major complaints. However, their spouse notes involuntary jaw movements and clenching, especially when distracted or tired. Clinical assessments discover facial asymmetry and tongue thrusting. 

The latter may resemble bruxism, but the timing, history, and involuntary movements suggest a neurogenic parafunction. Although parafunctions are frequently encountered in dental practice, their neurogenic origins are often overlooked. 

This clinical guide will fill a critical gap by highlighting how neurogenic conditions manifest as parafunctional behaviors. It will equip dental professionals to provide more accurate and empathetic patient care. 

Understanding Neurogenic Parafunction 

Let’s start by understanding parafunctional habits. Such behaviors are exclusive of normal functions like eating, speaking, or swallowing. Despite occurring without deliberate effort, they can damage an individual’s teeth, joints, muscles, and soft tissues over time. 

Here are a few examples of parafunctional habits: 

• Bruxism – It is the grinding or clenching of teeth during sleep or stress. 
• Tongue thrusting – The individual may push or thrust their tongue against their teeth, especially while swallowing. 
• Lip or cheek biting – The same is habitual and could be triggered by anxiety. 
• Object chewing – It could be any item not meant for the mouth, such as a pen or an eraser. 

Neurogenic parafunctions are more specific, as these habits originate from disturbances in the nervous system. In general, most parafunctional habits are linked to psychological stress, dental occlusions, and maladaptive behaviors. Conversely, neurogenic parafunctional behaviors are a byproduct of impaired neural function. 

In other words, the central or peripheral nervous system is often involved. Causes of neurogenic parafunction include stroke, acquired or traumatic brain injury (TBI), Parkinson’s disease, and Tourette’s syndrome. 

Patients may not even be aware of their behaviors (involuntary). Traditional interventions like nightguards may prove to be insufficient unless the underlying neurogenic dysfunction is addressed. 

Common Presentations in Neurogenic Cases 

In clinical cases, neurogenic parafunction may present itself subtly or dramatically. Here are a few examples: 

Bruxism Associated With Brain Injury 

On average, 22.22% is the global bruxism prevalence as found in a systematic review (2003-2023). Acquired brain injury (ABI) patients experienced excessive parafunctional jaw muscle activity, as reported in a recent study. 

The same occurrence following a traumatic brain injury is a growing area of clinical research. A 2025 scoping review found that just four studies had directly examined the connection. Naturally, the authors concluded that evidence remains limited or inconclusive. 

However, the fact that 50-60 million individuals suffer from a TBI annually reinforces the importance of screening for post-injury bruxism. Nowhere is this more essential than in cases where symptoms develop gradually or without patient awareness. 

Orofacial Dyskinesias 

This condition refers to the involuntary and repetitive movement of the jaw, lips, and tongue. Its symptoms may overlap with those of parafunctional habits like bruxism or tongue thrusting. They differ in that orofacial dyskinesias are neurological in origin, so the movements are not consciously controlled. 

Dentists may observe lip pursing or jaw deviation in post-stroke syndromes, tardive dyskinesia, or even Parkinson’s disease. A 2024 case report based on a 79-year-old man offered much insight. 

Published in Frontiers in Neurology, the report emphasized that orofacial symptoms were among the most frequent and functionally impairing features of tardive dyskinesia. The involuntary movements can affect speech and eating. Dentists often misinterpret them to be voluntary habits. 

Post-Stroke Muscular Imbalance 

It may take months or years to recover from a stroke, and many don’t ever recover fully. Such survivors often experience asymmetrical facial muscle function. This may lead to compensatory oral behaviors that mimic parafunctional habits. 

A multidisciplinary study conducted on 25 stroke survivors found that most (23) experienced objective orofacial dysfunction. Many were not even aware of their issues. Reduced lip strength, impaired chewing, and muscle weakness triggered compensatory parafunctional behaviors like tongue thrusting and unilateral clenching. 

Since many patients appeared asymptomatic, the study highlighted the drawbacks of subjective awareness. Dental professionals must conduct objective assessments of lip and jaw strength, even when bite examinations seem normal. 

Diagnostic Considerations for Dental Professionals 

Parafunctional neurogenic conditions cannot be diagnosed via standard behavioral evaluation. Dentists must shift their observation to a neurologically informed standpoint. Diagnostic considerations will include the following: 

Comprehensive Medical History 

Detailed patient histories will help understand if there are any emotional stressors, neurological conditions, or head trauma involved. Injuries, especially those sustained in road accidents, gradually manifest parafunctional symptoms like bruxism and tongue thrusting. 

Such cases are particularly relevant in high-traffic urban areas like Atlanta, Georgia. Clinicians occasionally encounter patients involved in motor vehicle collisions and workplace accidents. Atlanta personal injury attorneys may already be involved, working closely with dental professionals to document post-traumatic symptom progression. 

Many parafunctional symptoms manifest over weeks or months as the body’s neuromuscular system adapts. Accident victims may not be aware of their injuries until hours later. This stresses the importance of longitudinal documentation. Naturally, the parafunctional behaviors tied to neurogenic changes may only become apparent after the initial trauma. 

Intraoral and Extraoral Examinations

A thorough clinical evaluation, especially when trauma is involved, cannot be stressed enough. Dental professionals must conduct both extraoral and intraoral examinations to gain unique diagnostic clues from each. 

Extraoral examination would involve the structures and functions outside the oral cavity, like facial symmetry, muscle palpation, mandibular motion, and TMJ. Intraoral examination would focus on soft tissue health and function within the mouth. It would involve examining the teeth, occlusion, tongue, cheeks, and lips. 

Together, the assessments can help distinguish between behavioral parafunction and neurogenic disorders. The findings will also be insightful for interdisciplinary care. 

A Thorough Behavioral Assessment 

The step of behavioral assessment is also essential. It will help determine whether the patient’s parafunctional behaviors stem from stress/anxiety or are a reflection of involuntary movements consistent with neurogenic disorders. 

Dental professionals may participate in patient interviews and notetaking of their history. A structured conversation can reveal awareness of the habits, timing, context, and triggers. 

Besides standardized questionnaires, observation cues during consultation matter. It’s important to pay close attention to facial tension, jaw movements during conversation, and lip biting while at rest. 

A well-executed behavioral assessment leads to a more accurate diagnosis and a better selection of interventions. It also prevents mismanagement of the condition. 

Management Strategies 

Multifactorial treatment, often in collaboration with other healthcare providers, is the main strategy for neurogenic parafunction. Instead of eliminating the habit, dentists must focus on mitigating damage, reducing discomfort, and improving function. 

Here’s a breakdown of the common management strategies: 

• Occlusal appliances – Night guards and occlusal splints remain the primary tools for bruxism. If they fail, multimodal management is needed in the form of customized appliances, neurology referral, and speech-language therapy. 
• Physical therapy – TMJ-targeted exercises and postural correction can reduce muscular strain. Orofacial myofunctional therapy is required in some cases to restore coordinated movement patterns. 
• Botulinum toxin injections – They are reserved for severe cases of muscle overactivity. Low-dose botulinum toxin may help manage parafunctional behaviors without impairing mastication. 
• Behavioral modification and biofeedback – This strategy is only effective in cases of psychological overlay. Such patients regain muscle control through awareness training. 

The most important takeaway is how parafunctional behaviors originating in neurogenic conditions mimic stress-related clenching. Such is a recent case report. It was found that oromandibular dystonia (a neurogenic form of parafunction) can emerge weeks after orofacial trauma or dental procedures. 

The symptoms may subtly appear in dental settings, further highlighting the need to distinguish between stress-induced habits and those driven by neurogenic causes. This will ensure that patients receive targeted, interdisciplinary care for oral health as well as neurological well-being. 

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